Injuries around the

shoulder
Anatomy and incidence
Anatomy of shoulder joint
Anatomy of shoulder joint
Anatomy of shoulder joint
Anatomy of shoulder joint

anterior
Anatomy of shoulder joint

posterior
Incidence
Fractures of the clavicle
Effect of muscle forces on
fracture
Clinical features of fractures of
the clavicle
 Clinical features of fractures of
the clavicle
• Pain
• Swelling
• Tenderness depends on site
• Status of skin
• Check for vascular complication
• Neurological status
Classification
 Fractures of the clavicle

• Classified according to location- 

Group 1 = Midshaft fractures (76%)
Group 2 = lateral-end fractures (21%)
Group 3 = medial fractures (3%)
Middle third fracture
Lateral end of clavicle fracture
X-ray of fracture of the
clavicle
 Non-operative Management
• Sling, brace or strap
• Broad arm sling
• Figure of eight bandage or clavicular
brace (custom made)
 Operative Management

Indications:
1. Open fractures
2. Fractures with neurovascular
compromise
3. Floating shoulder (combined clavicle &
scapula fractures) .
4. Symptomatic non-union
Operative management

Stabilization with plate and screws

Fractures of the clavicle
Complications of fractures of the
clavicle
• Early-vascular, nerve, lung injury
• Late-malunion, nonunion (rare),
stiffness of shoulder
Fractures of the proximal humerus

Anatomy of the proximal humerus

Pathoanatomy
Pathoanatomy
 Fractures of the proximal
humerus
• Neer’s Classification
• Requirements to classify fractures:
• Adequate radiographs (= Trauma series
+/- CT scans)
• Knowledge of the pathology &
deforming forces
• Segment Angulation of 45deg.
• Segment Displacement of 1cm
 Radiographs

AP Lat
Axillary view
 Fractures of the proximal
humerus

1. One part fractures

Defined as no fracture fragments
displaced more than 1cm or 45deg.
Management
Treat by immobilization for 1-2 weeks
Mobilise when the head & shaft rotate
as a single unit.
 Fractures of the proximal
humerus

2. Two part fractures

Two fracture fragments displaced
more than 1cm or 45deg
The fracture is extra-articular &
therefore AVN not common.
 Fractures of the proximal
humerus
Management
Closed reduction can be attempted -
axial traction, adduction & flexion,
impact. 
Test for stability - if unstable then
insert percutaneous pins or
ORIF
Fractures of the proximal
humerus

Closed reduction and

use of percutaneous pins
Closed reduction and internal
fixation
Open reduction and internal
fixation
 Fractures of the proximal
humerus
3. Three part
fractures
Three fracture
fragments
displaced more
than 1cm or 45deg
Management
ORIF
ORIF
 Fractures of the proximal
humerus

4. Four part fractures

Four fracture fragments displaced
more than 1cm or 45deg
Management
In elderly patients with osteopaenic
bones, conservative management with
broad arm sling and rest
 Fractures of the proximal
humerus

4. Four part fractures

Management
In young patients proceed with open
reduction and internal fixation
ORIF
Shoulder joint replacement
 Complications
• Vascular and nerve injuries
• Stiffness of shoulder
• Malunion
• Avasuclar necrosis of head of humerus
 Shoulder Dislocation
• account for almost 50%
of all joint dislocations.
Classification
anterior (90-98%) and occur due to trauma.
subcoracoid (most common)
subglenoid
subclavicular
intrathoracic
Posterior
Inferior
 Anterior Dislocation

Mechanism of Injury :
- Forceful abduction or external rotation
- a direct blow to the posterior humerus
- forced elevation and external rotation
- fall on an outstretched hand
Normal shoulder
Normal shoulder Anterior dislocation
                                                                                                     

                           

Normal Shoulder Anterior dislocation

Normal Shoulder
Normal Shoulder Anterior dislocation
 Anterior Dislocation
Symptoms :
• Shoulder pain
• Restricted motion of the shoulder
• Abnormal alignment of shoulder (deformity)
• If the nerve is injured by the dislocated
bone-numbness occurs on the outside of
the arm
• Muscle weakness around the shoulder
 Anterior Dislocation
Signs:
• The arm in slight abduction and externally
rotated.
• The humeral head can often be palpated in
the front of the shoulder.
• Internal rotation and adduction are limited.
• Movement is usually very painful due to
muscle spasms.
Test for axillary nerve paresis
 Posterior dislocation
Posterior dislocations are less common (2-
10%)
Mechanism of injury :
1. an axial load applied to the adducted
and internally rotated arm.
2. Following electrocution or seizures
because of the strength imbalance
between the internal rotators and
external rotators
 Posterior dislocation
Clinical presentation :
• The arm is internally rotated and
adducted.
• External rotation is severely limited.
• Posterior prominence is usually palpable,
the anterior shoulder is flattened, and
the coracoid process is more prominent.
• These dislocations have been missed or
misdiagnosed as a frozen shoulder.
 Treatment
Non-Surgical Treatment:
Conservative Treatment of
Shoulder Dislocation
• Manipulation under anesthesia and
reduction
 Treatment
Reduction techniques
• The Hippocratic
method
longitudinal traction
on the arm and a
counterforce to the
axilla
 Treatment

•The Kocher method :

traction to the elbow with external
rotation of the humerus and adducting the
elbow chest.
 Treatment
• The Stimson method
requires the patient to be positioned
prone. The patient's arm is allowed to
hang over the edge of the bed with
about 10 pounds of weight hanging
from the wrist.
 Treatment
• The Milch method
very successful and relatively
atraumatic.
abduct the patient's arm with one hand
while applying pressure to the humeral
head with the other hand. When the
patient's arm is fully abducted, external
rotation and traction are applied.
                                                             
 Treatment
• Following the reduction of the shoulder,
the patient will be required to wear
either a simple sling or a specialized
sling (shoulder immobilizer).
• For the first dislocation the period of
immobilization is 3 to 6 weeks.
 Treatment
• With early reduction, immobilization and
progressive rehabilitation, the expected
recovery time is 10-16 weeks.
• Physical therapy that focuses on
strengthening the muscles that surround
and stabilize the shoulder can
significantly reduce the risk for re-injury.
• Activities, which involve overhead
motion, should initially be avoided.
 Complications

• Rotator cuff tear

• Nerve injury
• Vascular injury
• Fracture dislocation
• Shoulder stiffness
• Unreduced dislocation
• Recurrent dislocation
                                                       
Recurrent dislocation of shoulder
pathoanatomy
 Humeral Shaft Fracture
clinical & radiographic
examination
• pain, swelling, deformity, shortening,
abnormal motion
• two full-length views of the entire
humerus, at 90 degrees to each other,
with clear delineation of the shoulder
and elbow joints
Displacement
 Humeral Shaft Fracture
Classification
• Based on fracture
line
Transverse
oblique
spiral
comminuted
segmental
 Humeral Shaft Fracture
management
• Conservative management (98% rate of
union)
Hanging Cast
U cast
humeral brace
 Humeral Shaft Fracture
Management
Indications for Operative management
1. failure of closed treatment
- loss of reduction
- poor patient tolerance/compliance
2. open fractures
3. vascular injury/neurologic injury
4. segmental fractures
5. floating elbow
6. associated intra-articular fractures
 Humeral Shaft Fracture

Management
Techniques of Operative
management
• plate osteosynthesis
• intramedullary fixation
• External fixators
Humeral Shaft Fracture
Humeral Shaft Fracture
Humeral Shaft Fracture
Humeral Shaft Fracture
 Humeral Shaft Fracture
Complications
• Radial nerve injury: up to 18%
– Most commonly associated with M/3
fracture (Holstein Lewis fracture)
– Neurapraxia or axonotmesis; 90% will
resolve in 3 to 4 months
• Vascular injury
• Nonunion
Radial Nerve entrapment in a humeral fracture
Humeral Shaft Fracture
NON UNION